International Journal of

Environmental Research
and Public Health

Article
The Association between US Adolescents’ Weight
Status, Weight Perception, Weight Satisfaction,
and Their Physical Activity and Dietary Behaviors
Furong Xu 1, *, Steven A. Cohen 2 , Mary L. Greaney 2 and Geoffrey W. Greene 3
1 Department of Kinesiology, University of Rhode Island, Independence Square II, Kingston, RI 02881, USA
2 Health Studies Program, University of Rhode Island, Independence Square II, Kingston, RI 02881, USA;
steven_cohen@uri.edu (S.A.C.); mgreaney@uri.edu (M.L.G.)
3 Department of Nutrition and Food Sciences, University of Rhode Island, Fogarty Hall, Kingston, RI 02881,
USA; ggreene@uri.edu
* Correspondence: fxu2007@uri.edu; Tel.: +1-401-874-2412




Received: 17 August 2018; Accepted: 2 September 2018; Published: 5 September 2018


Abstract: Background: It remain unclear that the association between weight status, weight perception,
weight satisfaction and the clustering of physical activity (PA) and dietary behaviors in adolescents.
Method: A cross-sectional analysis of National Health and Nutrition Examination Survey and
the US Department of Agriculture’s Food Patterns Equivalents 2007–2014 data from adolescents
aged 12–17 years (n = 2965) was conducted. Multivariable logistic regression models adjusted for
demographic characteristics examined the association between weight status, weight perception,
weight satisfaction, and the four created lifestyle groups (healthier behaviors, healthier diet only,
physically active only, unhealthier behaviors). Results: Males with obesity were more likely to be
in the healthier diet only group than males with a normal weight (OR = 1.90, 95% CI: 1.02, 3.52).
Similar patterns were found in males who perceived themselves as being overweight or having obesity
(OR = 2.09, 95% CI: 1.09, 3.99) and males with obesity who perceived their weight status accurately
(OR = 2.33, 95% CI: 1.12, 4.88). Female respondents who were satisfied with their weight were 59%
less likely to be in the healthier diet only group than healthier behaviors group compared with
females who were weight dissatisfied (OR = 0.41, 95% CI: 0.23, 0.75). This pattern was not observed
in males. Conclusions: Clustering PA and dietary behaviors were associated with weight status and
weight perception for males but not females. Weight satisfaction was associated with clustered PA
and dietary behaviors for females. These findings are important for obesity prevention policies and
programs to better address adolescents’ obesity and reduce health disparities in this population.

Keywords: weight perception; weight satisfaction; physical activity; diet quality

1. Introduction
Currently 20.6% of US adolescents aged 12–19 have obesity [1]. This high prevalence of obesity
and its associated short- and long-term health risks [1,2] make addressing obesity in this population a
public health priority. Obesity among adolescents is often attributed to inadequate physical activity
(PA) and a poor diet [3–8], and obesity prevention efforts often focus on increasing PA and promoting
healthy diets to promote energy balance [7–11]. However, most available studies examining the
relationships between lifestyle behaviors and obesity among adolescents focus on either PA or dietary
behaviors [4–8]. Although an understanding of factors associated with both PA and dietary behaviors
is needed to inform obesity prevention efforts for adolescents, research examining these behaviors
simultaneously is lacking.

Int. J. Environ. Res. Public Health 2018, 15, 1931; doi:10.3390/ijerph15091931 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2018, 15, 1931 2 of 13

Weight perception, the way in which individuals view their body weight, may be associated
with adolescents PA and dietary behaviors [12]. Some evidence suggests that adolescents with
self-perceived overweight or obesity, regardless of weight perception accuracy, are less physically
active than those who perceive themselves as being normal weight [6,13–15]. They also are more
likely to make unhealthier dietary choices [15–17]. However, other studies have had inconsistent
results [18,19]. For example, Wong & Leatherdale found that adolescents who perceived themselves as
being overweight or having obesity are not necessarily physically inactive when compared with their
normal weight counterparts [18], and Fredrickson and colleagues found that adolescents’ awareness of
being overweight was not associated with their dietary choices [19].
Weight satisfaction, how one feels about his/her weight, also maybe associated with adolescents’
PA and dietary behaviors [20]. Research examining the relationship between weight satisfaction,
PA and dietary behaviors among adolescents is limited and inconsistent [19,21,22]. Therefore, there is
a need to examine this relationship among a nationally representative sample of US adolescents. Thus,
the purpose of the present study was to examine the association between adolescents’ weight status,
weight perception, weight satisfaction and the clustering of PA and dietary behaviors. Given that
associations could differ by sex, we examined these relationships in males and females respectively.

2. Methods
The current study was a cross-sectional analysis of data from the National Health and Nutrition
Examination Survey (NHANES) and the US Department of Agriculture’s Food Patterns Equivalents
(USDA-FPE) 2007–2014 datasets. NHANES data were collected via questionnaires (e.g., demographics,
weight perception or satisfaction, 24-h dietary recall) or measured (e.g., height and weight) with
response rates vary from 70–80% [23,24]. The USDA-FPE data examined in this study were the
dietary components assessed via 24-h dietary recalls [24,25]. The two datasets were merged using
participants’ study identification numbers and days of 24-h recalled dietary data. The present study
was exempted by University of Rhode Island Institutional Review Board as the data used for the study
are de-identified.

2.1. Analytic Sample

A total of 40,617 respondents were abstracted from NHANES and the USDA-FPE 2007–2014
datasets. Of these respondents, 3920 were 12–17 years of age. Of these, 3041 had complete data for
all examined variables including two days of dietary recalls. Of the 3041 respondents, 2.5% (n = 76)
were underweight based on body mass index (BMI, <5th percentile for BMI), and were excluded due
to possible underweight-related psychological or physical pathology issues [26] as well as the small
sample size. The final analytic sample included 2965 adolescents.

2.2. Weight Status

BMI was calculated using height and weight that was measured at the Mobile Examination
Center (MEC). BMI was used to determine weight status according to 2000 Centers for Disease Control
and Prevention growth charts (0–20 years): obesity (≥95th percentile), overweight (≥85th percentile
but <95th percentile), normal weight (≥5th percentile but normal <85th percentile, and underweight
(<5 the percentile) [27].

2.3. Weight Perception and Weight Perception Accuracy

Respondents’ weight perception was measured by a single-item question that asked them how
they considered their weight with the response options of fat or overweight, about right weight,
and thin [23]. Weight perception accuracy (accurate, inaccurate) was determined by comparing
perceived and measured weight status (normal, overweight, obese). If the two measures were
concordant, weight perception accuracy was considered to be accurate and if the two measures
were discordant weight perception accuracy was deemed inaccurate [6].
Int. J. Environ. Res. Public Health 2018, 15, 1931 3 of 13

2.4. Weight Satisfaction

Weight satisfaction was measured one of two ways depending on respondents’ age.
For respondents aged 12–15 years, it was assessed by a single item that asked what they would
like to do about their weight with the response options of: (1) lose weight, (2) gain weight, (3) stay the
same or (4) not trying to do anything about weight [23]. Respondents who wanted to “gain or lose
weight” were classified as being weight dissatisfied while those who reported that they were trying to
“stay the same or were not trying to do anything about their weight” were reported as being weight
satisfied. Respondents aged 16–17 were asked whether they would like to change their weight with
the response options of: (1) weigh more, (2) weigh less or (3) weigh the same [23], and those who
reported that they would like to weigh more or less were classified as being weight dissatisfied while
those who reported that they would like to weigh same were classified as being weight satisfied.

2.5. Physical Activity

PA was measured in three domains (work, travel, and recreational) using the Global Physical
Activity Questionnaire [23]. The metabolic equivalent of task (MET) minutes of moderate to
vigorous PA per week in each domain was determined and then summed to calculate total PA
time per week [23,28]. Respondents who participated in ≥1680 MET-minutes of PA per week were
classified as meeting current PA recommendations, all others were classified as not meeting PA
recommendations [29].

2.6. Diet Quality

Diet quality was determined using the National Cancer Institute’s simple Healthy Eating Index
2015 (HEI-2015) scoring algorithm [30,31], which is a reliable and valid measure of diet quality [24,30].
The HEI-2015 uses information from two 24-h dietary recalls conducted by NHANES to assess 13
dietary components (e.g., saturated fats, whole grains, etc.) [30]. The 13 components were summed
to create total diet quality scores (range 0 to 100) with a higher score indicating better diet quality
and greater adherence to the 2015–2020 Dietary Guidelines for Americans [31]. Participants were
stratified into tertiles based on their total dietary quality scores: (1) lower quality diet (scores <42.1);
(2) intermediate quality diet (scores 42.1–51.7); (3) healthier diet (scores >51.7). The top tertile was
viewed as being indicative of a healthier diet whereas another two tertiles (lower quality diet and
intermediate quality diet) were considered to indicate eating a less healthful diet.

2.7. Lifestyle Groups

Respondents were classified into four lifestyle groups based on their PA and dietary behaviors [29,
31]: Group 1, healthier behaviors: meeting PA recommendations and eating a healthier diet; Group 2,
healthier diet only: eating a healthier diet but not meeting PA recommendations; Group 3, physically
active only: meeting PA recommendations but eating a less healthful diet; and Group 4, unhealthier
behaviors: not meeting PA recommendations and eating a less healthful diet.

2.8. Demographic Characteristics

Examined demographic characteristics included age, sex, race/ethnicity (non-Hispanic White,
non-Hispanic Black, Mexican American, other Hispanic, others) and parental education levels (high
school or less, college or above) [25]. Family income and family size was used to calculate the
poverty-to-income ratio that was then used to determine if the household income was at/above (≥1)
or below (<1) federal poverty level [32]. NHANES has sampling design to assure reliable estimates of
various US population subgroups thus participants are representative of the US population [24,33].
Int. J. Environ. Res. Public Health 2018, 15, 1931 4 of 13

2.9. Statistical Analysis

The MEC exam 2-year weights were used for all analyses [33]. Descriptive results were
obtained for the sample and are presented as mean ± standard error for continuous variables and
frequencies and proportions for categorical variables. For the sex-specific prevalence of weight status,
weight perception, weight perception accuracy, and weight satisfaction by the lifestyle groups, p-values
for continuous variables were obtained by performing PROC SURVEYREG, and p-values for categorical
variable were obtained by performing PROC SURVEYLOGISTC to perform the adjusted analyses,
adjusting for age, race/ethnicity, parental education levels, and whether respondents lived at/above
or below the poverty line. Bonferroni corrections were conducted for all multiple comparisons.
To examine the association between weight status, weight perception, weight perception accuracy,
and weight satisfaction (independent variables) and the four lifestyle groups (dependent variable),
multivariable logistic regression models were performed with the use of PROC SURVEYLOGISTIC,
with GLOGIT link (multinomial logistic model) with Group 1, healthier behaviors group, being the
reference category to estimate the adjusted odds ratios. All models were adjusted for age, race/ethnicity,
parental education level, and poverty status, and stratified by sex. All analyses were conducted using
SAS version 9.4 (SAS Institute Inc., Cary, NC, USA) and significance was set at p < 0.05.

3. Results
Respondents’ mean age was 14.5 years, approximately half (49.7%) were females, 42.3% were
racial/ethnic minorities, 39.6% had a parent with a high school education or less, 19.4% lived below
the poverty line (see Table 1). About a quarter (20.8%) of respondents were classified as having obesity,
21.9% perceived themselves as being overweight or having obesity, 26% accurately perceived their
weight as being overweight or obese, 55.8% were dissatisfied with their weight, 85.2% of respondents
with obesity were dissatisfied with their weight.

Table 1. Sample characteristics stratified by sex (n = 2965).

Total Males Females

p Value
n = 2965 n = 1504 n = 1461
Gender, n (weighted %)
Males 1504 (50.3) - - -
Females 1461 (49.7) - - -
Age (years) (mean ± SE) 14.5 ± 0.0 14.5 ± 0.1 14.6 ± 0.1 0.409
Ethnicity, n (weighted %)
Non-Hispanic White 827 (57.7) 435 (57.4) 392 (57.9) 0.804
Non-Hispanic Black 748 (14.1) 378 (14.0) 370 (14.2) 0.856
Mexican American 695 (13.7) 346 (13.8) 349 (13.5) 0.787
Other Hispanic 342 (6.5) 171 (6.6) 171 (6.4) 0.772
Others 353 (8.0) 174 (8.1) 179 (7.9) 0.857
Parent education level, n (weighted %)
High school or less 1420 (39.6) 719 (38.9) 701 (40.3) 0.524
College or above 1451 (60.4) 736 (61.1) 715 (59.7) 0.524
Poverty to income ratio, n (weighted %)
<1.0 793 (19.4) 394 (19.0) 399 (19.9) 0.589
≥1.0 1941 (80.6) 994 (81.0) 947 (80.1) 0.589
BMI (kg/m2 ) 23.5 ± 0.1 23.4 ± 0.2 23.6 ± 0.2 0.446
Weight status, n (weighted %)
Normal weight 1765 (62.1) 905 (60.6) 860 (63.6) 0.308
Overweight 521 (17.1) 254 (17.6) 267 (16.6) 0.604
Obesity 679 (20.8) 345 (21.8) 334 (19.8) 0.291
Perceived weight status, n (weighted %)
Thin 196 (5.5) 128 (7.3) 68 (3.6) <0.001 *
Normal 2055 (72.6) 1093 (75.6) 962 (69.6) <0.001 *
Overweight/Obese 714 (21.9) 283 (17.1) 431 (26.8) <0.001 *
Accurate weight perception #
Normal 1481 (74.1) 760 (76.3) 721 (72.0) 0.072
Overweight 148 (6.4) 46 (4.3) 102 (8.3) 0.012 *
Obese 471 (19.6) 217 (19.4) 254 (19.7) 0.898
Int. J. Environ. Res. Public Health 2018, 15, 1931 5 of 13

Table 1. Cont.

Total Males Females

p Value
n = 2965 n = 1504 n = 1461
Weight satisfaction, n (weighted %)
Satisfied 938 (44.2) 471 (46.0) 467 (42.6) 0.191
Dissatisfied 1358 (55.8) 634 (54.0) 724 (57.4) 0.191
Weight satisfaction by weight category, n (weighted %)
Normal weight
Satisfied 727(61.6) 343(61.6) 384(61.6) 0.993
Dissatisfied 474(38.4) 225(38.4) 249(38.4) 0.993
Overweight
Satisfied 134(33.8) 80(45.0) 54(21.9) <0.001 *
Dissatisfied 313(66.2) 132(55.0) 181(78.1) <0.001 *
Obesity
Satisfied 77(14.8) 48(18.7) 29(10.6) 0.079
Dissatisfied 571(85.2) 277(81.3) 294(89.4) 0.079
Physical activity (PA)
2798.1 ± 3350.7 ± 2239.8 ±
Total PA (MET-minutes/week) <0.001 *
85.2 121.7 92.1
$,
Met PA recommendation n (weighted %) 1491 (54.9) 900 (63.8) 591 (45.9) <0.001 *
Sedentary (sitting) in minutes/day 498.1 ± 5.5 489.1 ± 7.1 507.1 ± 6.4 0.026 *
Diet quality score (HEI 2015)
Total diet quality (mean ± SE) 47.5 ± 0.3 46.9 ± 0.4 48.1 ± 0.4 0.016 *
Tertile classification of total diet quality score, n (weighted %)
First tertile (<42.1) 978 (34.3) 517 (34.7) 461 (34.0) 0.741
Second tertile (42.1–51.7) 978 (32.7) 518 (34.6) 460 (30.8) 0.108
Third tertile (>51.7) 1009 (32.9) 469 (30.7) 540 (35.2) 0.023 *
Note: Data are present as weighted mean ± standard error (SE) unless otherwise specified; $ accumulated ≥1680
MET minutes/week for 12–17 years old, HEI = Health Eating Index; # weigh perception accuracy defined as
consistency of perceived and measured weight status. If the two measures were concordant, weight perception
accuracy was considered to be accurate; * p < 0.05.

In regards to the examined behaviors, 32.9% had diets that were classified as being a healthier diet
and 54.9% met current PA recommendations. About one-fifth (18.6%) of respondents were classified as
being in Group 1, the healthier behaviors group, indicating that they met current PA recommendations
and ate a healthier diet (see Table 2). More females than males were in Group 2, healthier diet only
group (17.2% females vs. 11.4% males, p < 0.001), and Group 4, unhealthier behaviors group (36.9% vs.
24.7%, p < 0.001), whereas more males were in Group 3, physically active only group (44.5% males vs.
27.9% females, p < 0.001) (see Table 2).

Table 2. Lifestyle groups stratified by sex (n = 2965).

Proportion Difference between

Total Males Females p Value
Females and Males (95% CI)
Groups, n (weighted %) n = 2965 n = 1504 n = 1461 n = 2965
Group 1: Healthier behaviors 515 (18.6) 282 (19.3) 233 (18.0) −1.27 (−4.84, 2.31) 0.481
Group 2: Healthier diet only 494 (14.3) 187 (11.4) 307 (17.2) 5.75 (2.56, 8.94) <0.001 *
Group 3: Physically active only 976 (36.3) 618 (44.5) 358 (27.9) −16.63 (−20.1, −13.15) <0.001 *
Group 4: Unhealthier behaviors 980 (30.8) 417 (24.7) 563 (36.9) 12.14 (8.48, 15.81) <0.001 *
Note: Data are present as weighted mean ± standard error unless otherwise specified; CI = confidence interval;
* p < 0.05.

As shown in Table 3, Figures 1 and 2, there were differences in weight status by lifestyle
groups. A greater proportion of normal measured/perceived weight males as well as weight satisfied
females were in Group 1, the healthier behaviors group, than Group 2, healthier diet only group,
while males who perceived themselves as being overweight or having obesity and females who were
weight dissatisfied were more likely to be in Group 2, the healthier diet only group, than Group 1,
healthier behaviors group. Moreover, males with self-perceived overweight or obesity and females with
obesity were more likely to be in Group 2, the healthier diet only group, than Group 3, the physically
active only group.
 Int. J. Environ. Res. Public Health 2018, 15, 1931 6 of 13
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Int. J. Environ. Res. Public Health 2018, 15, 1931 7 of 13

Table 3. Associations between weight perception, weight satisfaction and lifestyle groups (n = 2965).

Group 1: Healthier Behaviors Group 2: Healthier Diet Only Group 3: Physically Active Only Group 4: Unhealthier Behaviors Overall p Value
Males (n = 1504) n = 282 (19.3%) n = 187 (11.4%) n = 618 (44.5%) n = 417 (24.7%)
Weight status
Normal weight 173 (65.9) 92 (48.7) a 386 (62.1) 254 (59.2) c 0.017 *
Overweight 43 (12.8) 37 (20.6) 109 (20.1) 65 (15.6) 0.041 *
Obese 66 (21.4) 58 (30.7) 123 (17.7) 98 (25.2) 0.038 *
Perceived weight status
Thin 18 (5.0) 16 (7.8) 58 (7.9) 36 (7.9) 0.258
Normal 210 (78.1) 121 (66.4) a 466 (79.3) 296 (71.0) 0.022 *
Overweight/Obese 54 (16.9) 50 (25.8) a 94 (12.8) b 85 (21.1) 0.005 *
Accurate weight perception
Normal 150 (79.3) 73 (61.7) a 323 (81.5) b 214 (71.4) 0.007 *
Overweight 7 (3.2) 9 (6.9) 13 (2.5) 17 (6.9) 0.048 *
Obese 41 (17.5) 38 (31.5) 75 (16.0) 63 (21.7) 0.045 *
Weight satisfaction
Satisfied 94 (53.0) 54 (43.8) 193 (44.7) 130 (43.9) 0.468
Dissatisfied 119 (47.0) 94 (56.2) 255 (55.3) 166 (56.1) 0.468
Females (n = 1461) n = 233 (18.0%) n = 307 (17.2%) n = 358 (27.9%) n = 563 (36.9%)
Weight status
Normal weight 145 (68.0) 165 (56.3) 216 (68.8) 334 (60.9) 0.222
Overweight 42 (16.7) 58 (15.7) 74 (17.0) 93 (16.6) 0.956
Obese 46 (15.3) 84 (28.1) 68 (14.2) b 136 (22.5) 0.007 *
Perceived weight status
Thin 9 (3.4) 16 (4.7) 15 (2.8) 28 (3.8) 0.538
Normal 168 (73.7) 181 (59.2) 250 (75.4) b 363 (68.1) 0.023 *
Overweight/Obese 56 (23.0) 110 (36.1) 93 (21.8) b 172 (28.1) 0.049 *
Accurate weight perception
Normal 132 (76.4) 132 (60.6) 182 (78.7) b 275 (69.7) 0.036 *
Overweight 15 (8.2) 30 (11.1) 25 (7.8) 32 (7.4) 0.863
Obese 35 (15.5) 63 (28.3) 49 (13.5) 107 (22.9) 0.011 *
Weight satisfaction
Satisfied 88 (52.0) 80 (29.1) a 110 (43.5) 189 (43.8) c 0.009 *
Dissatisfied 103 (48.0) 175 (70.9) a 178 (56.5) 268 (56.2) c 0.009 *
Note: Data are presented as n (weighted %); p-value for continuous variables was obtained by performing PROC SURVEYREG, and p-value for category variable was obtained by
performing PROC SURVEYLOGISTC to perform the adjusted analyses, adjusted for age, race, parental education level and poverty status; Bonferroni corrections were used for all multiple
comparisons; a Group 1 differed from Group 2 with a p < 0.05; b Group 2 differed from Group 3 with a p < 0.05; c Group 2 differed from Group 4 with a p < 0.05; * p < 0.05.
Int. J. Environ. Res. Public Health 2018, 15, 1931 8 of 13

Table 4. Adjusted odd ratios of lifestyle groups related to weight status, weight perception, and weight satisfaction (n = 2965).

Group 2: Healthier Diet Only vs. Group 1: Group 3: Physically Active Only vs. Group 1: Group 4: Unhealthier Behaviors vs. Group 1:
Healthier Behaviors Healthier Behaviors Healthier Behaviors
Males (n = 1504) Adjusted ORs (95% CI) p Value Adjusted ORs (95% CI) p Value Adjusted ORs (95% CI) p Value
Weight status
Normal weight 1.0 (REF) 1.0 (REF) 1.0 (REF)
Overweight 2.33 (1.15, 4.68) 0.016* 1.73 (1.00, 3.00) 0.046 * 1.21 (0.67, 2.19) 0.528
Obese 1.90 (1.02, 3.52) 0.038* 0.85 (0.50, 1.44) 0.537 1.14 (0.69, 1.86) 0.605
Perceived weight status
Normal 1.0 (REF) 1.0 (REF) 1.0 (REF)
Thin 0.89 (0.34, 2.32) 0.805 1.43 (0.71, 2.88) 0.308 1.45 (0.71, 2.95) 0.301
Overweight/Obese 2.09 (1.09, 3.99) 0.024* 0.82 (0.49, 1.38) 0.444 1.37 (0.87, 2.16) 0.164
Accurate weight perception
Normal 1.0 (REF) 1.0 (REF) 1.0 (REF)
Overweight 3.87 (1.01, 15.69) 0.047 * 1.09 (0.33, 3.63) 0.886 3.15 (1.00, 10.04) 0.048 *
Obese 2.33 (1.12, 4.88) 0.022 * 0.90 (0.48, 1.68) 0.74 1.18 (0.66, 2.10) 0.571
Weight satisfaction
Dissatisfied 1.0 (REF) 1.0 (REF) 1.0 (REF)
Satisfied 0.69 (0.40, 1.19) 0.174 0.73 (0.46, 1.15) 0.165 0.75 (0.45, 1.24) 0.256
Females (n = 1461)
Weight status
Normal weight 1.0 (REF) 1.0 (REF) 1.0 (REF)
Overweight 1.05 (0.51, 2.17) 0.885 1.02 (0.51, 2.05) 0.953 1.06 (0.56, 2.00) 0.856
Obese 1.97 (0.96, 4.04) 0.058 0.92 (0.51, 1.66) 0.779 1.52 (0.85, 2.73) 0.153
Perceived weight status
Normal 1.0 (REF) 1.0 (REF) 1.0 (REF)
Thin 1.47 (0.37, 5.80) 0.576 0.54 (0.13, 2.19) 0.383 1.04 (0.27, 3.98) 0.949
Overweight/Obese 1.53 (0.83, 2.84) 0.167 0.84 (0.51, 1.38) 0.472 1.25 (0.75, 2.10) 0.378
Accurate weight perception
Normal 1.0 (REF) 1.0 (REF) 1.0 (REF)
Overweight 1.41 (0.48, 4.20) 0.525 0.86 (0.39, 1.87) 0.69 0.94 (0.37, 2.36) 0.889
Obese 1.80 (0.87, 3.72) 0.105 0.79 (0.41, 1.53) 0.477 1.42 (0.74, 2.70) 0.28
Weight satisfaction
Dissatisfied 1.0 (REF) 1.0 (REF) 1.0 (REF)
Satisfied 0.41 (0.23, 0.75) 0.003 * 0.74 (0.43, 1.27) 0.269 0.74 (0.41, 1.34) 0.307
Note: ORs = odds ratios; REF = reference; Adjusted ORs were obtained by PROC SURVEYLOGISTIC using the generalized logit model with the LINKG = LOGIT option (multinomial
logistic model), adjusted for age, race/ethnicity, parental education level, poverty status; * p < 0.05.
Int. J. Environ. Res. Public Health 2018, 15, 1931 9 of 13

Comparing Group 1, the healthier behaviors group, to the other three lifestyle groups by weight
categories, males with overweight or obesity were more likely to be in Group 2, the healthier diet
only group, than males with normal weight (see Table 4). More specifically, males with obesity were
90% more likely to be in Group 2, the healthier diet only group, than Group 1, healthier behaviors
group, compared to males of normal weight (OR = 1.90, 95% CI: 1.02, 3.52). Similarly, males who
perceived themselves as being overweight or having obesity (OR = 2.09, 95% CI: 1.09, 3.99) and those
who accurately perceived themselves as having obesity (OR = 2.33, 95% CI: 1.12, 4.88) were more likely
to be in Group 2 than Group 1. Males who accurately perceived themselves as being overweight were
more likely to be in Group 2, the healthier diet only group (OR = 3.87, 95% CI: 1.01, 15.69) or Group
4, unhealthier behaviors group (OR = 3.15, 95% CI: 1.00, 10.04) than males who accurately perceived
themselves as being normal weight (Table 4). No statistical difference was observed between males
who were satisfied with their weight and those who were weight dissatisfied.
For females, there was no significant association between weight status, weight perception or
weight perception accuracy by lifestyle groups. Females who were satisfied with their weight were
59% less likely to be in Group 2, healthier diet only group, than Group 1, the healthier behaviors group,
compared with those who were dissatisfied with their weight (OR = 0.41, 95% CI: 0.23, 0.75).

4. Discussion
The present study used a nationally representative sample of adolescents to examine differences
in four lifestyle groups characterized by the clustering of PA and dietary behaviors by weight status,
weight perception, and weight satisfaction. Study results extended previous research findings by
documenting that males with overweight or obesity or self-perceived overweight or obesity were less
likely to meet PA recommendations than males with normal weight but diet quality did not differ [34].
Results of the current study also determined that females who were satisfied with their weight were
more likely to meet PA recommendations and have a healthful diet than those who were dissatisfied
with their weight. These findings indicate that lifestyle behaviors for males differ by weight status and
weight perception whereas lifestyle behaviors for females differ by weight satisfaction.
In the present study, 54.9% of respondents were classified as meeting current PA recommendations,
32.9% had healthier diets. However, only 18.6% of the sample met PA recommendations and ate a more
healthful diet. Although these finding are consistent with previous studies examining PA and/or diet
quality among adolescents [4,11,35,36], no prior studies to our knowledge, examined the clustering of
PA and dietary behaviors using a representative sample of US adolescents. Moreover, no identified
studies assessed diet quality using the HEI-2015, which examines adherence to 2015–2020 dietary
Guidelines for Americans [30]. The HEI-2015 differs from prior versions in assessed components and
scoring, but, the average diet quality score of 47.5 in the current study is comparable to HEI-2010 mean
score of 48.4 found in adolescents aged 12–18 from NHANES 2011–2012 [37]. Although the upper
tertile (HEI-2015 scores >51.7) was defined as being a healthier diet for this study, according to the
original HEI rating system, scores 51–80 indicate a diet that needs improvement [38]. Furthermore,
the present study revealed sex differences across lifestyle groups: more females than males were in
the healthier diet only group and the unhealthier behaviors group whereas more males than females
were in the physically active only group. This finding is consistent with prior research that had found
males to be more physically active than females [6,14] but differs from findings from other research
who found that males had better dietary quality than females [35,39]. However, such results should
be interpreted with caution because the clustering of PA and dietary behaviors were not examined in
these studies [6,14,35,39].
Study findings indicate that males with overweight or obesity or who perceived themselves
as being overweight or having obesity were more likely to consume a healthier diet but less likely
to meet the PA recommendations than males with a normal weight or perceived their weight to be
normal. However, similar results were not found among females. This finding differs from that of prior
studies who have found that adolescents with self-perceived overweight or obesity were physically
Int. J. Environ. Res. Public Health 2018, 15, 1931 10 of 13

inactive [6,14,15] but not related to dietary choices [40], although comparisons between these studies
should be made with caution considering that the current study examined individuals’ PA and dietary
behavior cluster. Moreover, the present study found that males who accurately perceived themselves
as being overweight were more likely have unhealthier lifestyle behaviors. These findings suggest that
for males recognizing oneself as being overweight may be a barrier to participating in PA and eating a
healthier diet but this might not the case for males with obesity. These findings also suggest that sex
differences in the relationship of weight status, weight perception and lifestyle behaviors should be
considered while tailoring suitable obesity prevention or intervention strategies to address the unique
needs of males and females with obesity in different lifestyle behavior groups.
Additionally, although the percentage of adolescents who were weight satisfied in this study
is comparable to other studies [19,40], no difference in weight satisfaction by sex were observed as
other studies have found [19,40]. This could be due to the use of a single item assessing weight
satisfaction in the current study compared to other research [19,40]. Furthermore, differences in weight
satisfaction by lifestyle groups were observed only among females. Females who satisfied with their
weight were more likely in the healthier behaviors group, meeting PA recommendations and eating a
healthier diet, than females who dissatisfied with their weight. Fredrickson and colleagues also have
found that weight satisfaction is associated with healthy behaviors such as meeting the daily fruit
recommendations but not related to daily servings of vegetables or PA [19]. Nevertheless, the present
study extends previous research by examining PA and overall diet quality in tandem, which provides
important insights for obesity prevention efforts and support the idea that weight satisfaction may
serve as motivating factor for females engaging in healthy behaviors.
Study strengths include the use of a nationally representative sample that is racially/ethnically
diverse (42.3% identifying as racial/ethnic minorities) and parents with less than a college education
(39.6%), to examine the association of weight status, weight perception, weight satisfaction, and the
clustering of PA and dietary behaviors. An additional study strength is use of measured height and
weight to determine weight status as well as the use of 24-h recall methodology instead of a food
frequency questionnaire. This also is the first study using HEI-2015 as an overall measure of dietary
quality in adolescents. Study limitations include its cross-sectional design which does not allow
for causality evaluation, weight satisfaction assessed using a single-item, and PA measured using a
self-reported instrument. In addition, healthier PA was defined as meeting guidelines but since no
guidelines exist for HEI-2015, healthier was defined as the upper tertile. This resulted in a greater
proportion of adolescents meeting the PA cutoff for healthier than the dietary cutoff for healthier, thus
results must be interpreted with caution. Nevertheless, all the measures are widely used and the study
utilized validated instruments [24,28–30].

5. Conclusions
There were differences in weight status and weight perception by lifestyle group, and these
differences were largely driven by PA for males and diet quality for females. Males with overweight
or obesity were more likely not to meet PA recommendations but tended to have a higher quality
diet than males with normal weight. Similar pattern was also observed in males with self-perceived
overweight or obesity. Whereas females who were weight satisfied were more likely to meet the
PA recommendation and eat a healthier diet than females who were dissatisfied with their weight.
These results indicate that the importance of weight status, weight perception, and weight satisfaction
in the adoption of healthier lifestyle behaviors particularly for individuals with overweight or obesity.
Our findings also suggest that examining PA and dietary behavior cluster instead of either/or in the
present study provides important insights on lifestyle behaviors difference that can be used to frame
future research or interventions.
Int. J. Environ. Res. Public Health 2018, 15, 1931 11 of 13

Author Contributions: F.X., M.L.G. and S.A.C. designed the study. F.X. drafted the manuscript and F.X., M.L.G.,
S.A.C. and G.W.G. reviewed and provided edits and critical feedback. F.X. conducted all analyses with assistance
from S.A.C. All authors approved the final version of the manuscripts.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest regarding this paper.
Declaration: All data are publicly accessible and available in the NHANES repository, https://wwwn.cdc.
gov/nchs/nhanes/sasviewer.aspx or United States Department of Agriculture’s Food Patterns Equivalents
Database, https://www.ars.usda.gov/northeast-area/beltsville-md-bhnrc/beltsville-human-nutrition-research-
center/food-surveys-research-group/docs/fped-data-tables/.

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